Provider Demographics
NPI:1962132753
Name:SOUTH, JADE (LSW)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10257 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4418
Mailing Address - Country:US
Mailing Address - Phone:618-826-4547
Mailing Address - Fax:618-615-4288
Practice Address - Street 1:10257 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4418
Practice Address - Country:US
Practice Address - Phone:618-826-4547
Practice Address - Fax:618-615-4288
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108127104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker